Caregivers’ use of insecticide-treated nets is associated with the use of ITNs by children under the age of five in Ghana

Background Malaria poses a greater risk to children under the age of five years due to its high morbidity and mortality rates. The use of Insecticide-Treated Net (ITN) has been proven to be an effective preventive intervention in the control of malaria. However, its utilisation remains low. This study assessed the association of mother or caregiver’s utilisation of ITN on its use by their children under five years of age in Ghana. Methods This study used data from the 2019 Ghana Malaria Indicator Survey (GMIS). The study analysed a weighted sample of 1,876 women aged 15–49 years who had at least one child under the age of five. In this study, the outcome variable is mosquito bed net use in children under five years. We performed descriptive statistics, chi-square tests, and multinomial logistic regressions. Results Of the women studied, 58.59% [95% CI: 55.39, 61.71] slept under mosquito bed nets the previous night. The utilisation of ITN in children under five was 61.88% [95% CI: 58.43, 65.2] on the night before the study. The adjusted logistic regression revealed that mothers/caregivers who slept under a mosquito bed net were more likely to have their children under five years of age sleeping under a mosquito bed net (RRR = 2.47, 95% CI: 1.48, 4.12; p <0.001). In addition, the use of ITN in children under five was also found to be predicted by the number of ANC visits, the number of children under five in the household, and wealth status. Conclusion The study found that the use of ITN by mothers/caregivers and their children remains low in Ghana. Nevertheless, we found that when a mother uses ITN, her children under the age of five are more likely to use it as well.

Introduction influencing behavioural practice, health promotion programmes and/or interventions can be successfully incorporated into people's daily lives to bring about improvements in health behaviour [14]. The Health Belief Model (HBM) is a health-focused behavioral cognitive model [15]. ITN use is influenced by human behavioural and social aspects because ITN programmes depend on the acceptance and active participation of individuals and communities [5]. HBM comprises six dimensions, including self-efficacy, perceived benefit, perceived barrier, perceived susceptibility, and cues to action [16]. The HBM makes the assumption that if a person thinks that a bad health condition can be prevented, he or she will act in a way that is connected to their health. Similarly, the model implies that a person will act appropriately if they have a positive expectation that by taking a recommended action, they can prevent a negative health problem [17]. It has been discovered that the season, along with power dynamics within the household, influences the use of mosquito nets [18]. In an exploratory study conducted in rural Burkina Faso, Okrah et al. found that the majority of bed nets were used by adults, particularly household heads, and that they were mostly used during the rainy season [19]. According to Mugisha and Arinaitwe, the majority of children in Uganda use mosquito nets, mostly because they share a bed with their parents [20]. ITN use has been reported to lower overall child mortality by 63% in villages employing treated nets [21] and to have a 50% preventive effect against malaria outbreaks in highly endemic areas of Africa [22]. The HBM framework was utilised in this study to investigate ITN use in light of decreased malaria risk.

Methods
In this study, the analysis is based on data collected from the 2019 Ghana Malaria Indicator Survey (GMIS). The sampling frame for the 2019 GMIS was based on the 2010 Population and Housing Census (PHC), which was done by the Ghana Statistical Service (GSS) in Ghana. Ghana created six (6) new regions in 2019, totaling 16 regions and 260 administrative districts, municipalities, and smetropolitans [23]. However, the new administrative boundaries were not available during the survey design. As a result, the sampling frame for the 2019 GMIS was based on the ten regional borders set under the 2010 PHC. The GMIS is a nationally representative cross-sectional household survey used to collect information on population-based malaria indicators for the country as a whole, for urban and rural areas separately, and for each of the ten (10) administrative regions (Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Northern, Upper East, and Upper West) as defined in the Ghana 2010 Population and Housing Census (PHC). The sampling frame used for the 2019 GMIS is a frame of all census enumeration areas (EAs) created for the 2010 Population and Housing Census (PHC) and provided by the Ghana Statistical Service (GSS) [10].
The 2019 GMIS sample was stratified and selected from the sampling frame in two stages. Each region was divided into urban and rural areas; this yielded 20 strata for sampling. Samples of EAs were selected independently in each stratum in two stages. Implicit stratification with proportional allocation was achieved at each of the lower administrative levels by sorting the sampling frame within each sampling stratum before sample selection [10]. This was performed according to administrative units at different levels and by using a probability proportional to size selection in the first stage of sampling. In the first stage, 200 EAs (97 in urban areas and 103 in rural areas) were selected with a probability proportional to EA size and with independent selection in each sampling stratum. In the second stage of selection, a fixed number of 30 households were selected from each stratum to make up a total sample size of 6,000 households. The sampling details for the 2019 GMIS, data collection methods and tools, as well as the quality control measures, have been documented in the full report [10].
This study utilised the children's file for analysis. A total of 1,876 women aged 15-49 years were included in the study.

Dependent variable
In this study, the dependent variable was the use of ITN by children under five years of age the night before the interview. The response options were no child (coded "0"), all children (coded "1"), and some children (coded "2"). We used some children (coded "2") as the base outcome of the dependent variable in the multinomial logistic regression. The use of ITNs the night before the interview might be tentative, as it may not reflect the true pattern of usage of ITNs by children under five. That is, respondents might not have used ITNs for some time but used them the night before the interview.

Covariates
The following sociodemographic and economic characteristics were included in the study as covariates: respondents' age group; highest level of education; place of residence; number of children under 5 in household; wealth index; use of ITN by the respondent; having a valid national health insurance card; the number of antenatal care (ANC) visits during pregnancy of their last child; being pregnant at the time of the interview; exposure to information on malaria within the past 6 months; and whether mothers or caregivers would allow their children under five to be vaccinated against malaria [13,24].
The levels of wealth index were already created in the dataset. However, the wealth index was generated in the 2019 GMIS as follows: "Scores were assigned to households based on the quantity and kind of consumer goods they own, including a television to a bicycle or automobile, as well as home factors like the source of drinking water, the availability of restrooms, and the type of flooring. With the help of principal component analysis, these scores were created. Each typical (de jure) household member is given a score, which is then used to rank each person in the household population. The distribution is then split into five equal categories, each of which has 20% of the population" [10].

Statistical analysis
The study used descriptive and inferential statistical analyses. The descriptive statistics and Pearson Chi-square goodness-of-fit test were computed for the percentage of children under five who slept under ITN and other demographic and economic characteristics to establish the significant difference between them. We performed multinomial logistic regression to examine the determinants of ITN use in children under five years of age. We used some children (coded "2") as the base outcome of the dependent variable in the multinomial logistic regression. We adjusted for the effect of sociodemographic and economic factors on the use of ITN by children under five. A test for multicollinearity was performed before fitting the adjusted model, and we found that there was no collinearity (mean VIF = 1.23, range = 1.01-2.04). To adjust for the complex survey design used in the GMIS, sampling weight was applied in all the analyses [25]. All statistical analyses were conducted using Stata version 15.0 (StataCorp. LP, College Station, USA). The results are presented as relative risk ratios (RRR) with their corresponding 95% confidence intervals (CIs). The statistical significance level was set at a p<0.05.

Ethical consideration
This study analysed secondary data from the 2019 Ghana Malaria Indicator Survey (GMIS). The protocol for the 2019 GMIS was approved by the Ghana Health Service Ethics Review Committee and the Inner-City Fund's Institutional Review Board. The authors were permitted to use the data by MEASURE DHS/ICF International. The Malaria Indicator Survey (MIS) Programme adheres to industry guidelines for protecting the privacy of respondents. ICF International guarantees that the survey complies with the Human Subjects Protection Act of the United States Department of Health and Human Services. Before the survey, the MIS project sought and received the required ethical approval. This study, therefore, did not require any additional approvals. More information on data and ethical principles can be found at http://goo.gl/ny8T6X.

The percentage of children under five sleeping under insecticide-treated bed nets by mothers' background characteristics
In total, 1,876 mothers/caregivers with children under five years of age participated in the study. The results showed that 28.15% of the households did not have children under five years of age sleeping under mosquito bed nets the previous night before the study; 57.94% had all children under five sleeping under bed nets the previous night; and 13.91% had some children under five sleeping under mosquito bed nets the previous night before the interview. We found significant differences in the use of ITN by children under five by all the sociodemographic, economic, and health-related characteristics except respondents' age group (pvalue = 0.275), being pregnant at the time of interview (p-value = 0.120), having a valid national health insurance card (p-value = 0.137), seeing or hearing any messages about malaria in the past 6 months (p-value = 0.289), and mothers/caregivers who would allow their children to be vaccinated against malaria (p-value = 0.198) ( Table 1).

Association between children under five sleeping under ITN and background characteristics of their mothers or caregivers
The use of bed nets in children under five was categorised as "no child under 5 slept under ITN the previous night", "all children under 5 slept under ITN the previous night" and "some children under 5 slept under ITN the previous night (the base outcome)." The results indicate that women who slept under mosquito bed nets were more likely to have their children under five sleeping under mosquito bed nets. In the multinomial logistic regression model, we adjusted for the effect of sociodemographic, and economic factors on children under five sleeping under mosquito bed nets the night before the study. The results showed that mothers/ caregivers who slept under a mosquito bed net were less likely to have no child sleeping under a mosquito bed net (RRR = 0.031; 95% CI: 0.015, 0.059). However, they were more likely to have all children sleeping under a mosquito bed net (RRR = 2.468; 95% CI: 1.477, 4.123) compared to having some children sleeping under a mosquito bed net last night.
Again, we found that the mothers/caregivers who made 4 to 7 ANC visits during pregnancy were 19% less likely to have a child sleep under ITN as compared to those who made no ANC visits. Wealthier mothers and caregivers are more likely to allow no child to sleep under ITN.
Moreover, mothers/caregivers with at least two (2) children under the age of 5 were less likely to have no child and all children sleep under ITN. Whereas respondents who are willing to allow their children under five to be vaccinated against malaria were 3.22 times more likely to have no child sleep under ITN last night. On the other hand, the mother/caregiver's age, education, place of residence, having a valid national health insurance card, being pregnant at the time of the interview, and having seen or heard of any messages about malaria in the past 6 months were not significantly associated with children under 5 sleeping under mosquito bed nets (Table 2).

Discussion
This study assessed the association between the use of ITN in children under five and their mothers/caregivers using nationally representative data from the 2019 MIS in Ghana. The study found that 58.59% and 61.88% of mothers/caregivers and children under five years old, respectively, slept under a mosquito bed net the night before the interview. This result is similar to a study conducted in Burkina Faso, which found that two-thirds (67.0%) of children under five sleep under the ITN [26]. In contrast, a study conducted in Nigeria that compared the level of usage among mothers/caregivers and children under five indicated that 49.1% of women and 43.1% of children under five slept under ITN the previous night before the conduct of the study [27] and 45.3% of women and 37.5% of children under five slept under ITN the previous night before the conduct of the study [28]. These are substantiated by the fact that, in Ghana and the majority of African nations, the Ministry of Health has made concerted efforts to provide education on malaria prevention with a strong emphasis on the use of ITN as the simplest and most effective method, with the assistance of WHO and UNICEF [29].
In the current study, it was found that the use of ITN in children under five years of age improved over the 2008 and 2014 Ghana Demographic and Health Surveys, which reported 41% and 47%, respectively [30,31]. This improvement may be attributed to the effort of the malaria control programme in the country towards the universal coverage target of 80% and above [32]. Other studies also reported increases in the usage of ITN [33,34]. However, about 40.0% of children did not use ITN on the night before the conduct of the interview in the country. This may be due to the high room temperature [35][36][37]; the use of other malaria preventive methods such as repellants [38]; and the poor quality of ITN [39].
After controlling for a number of factors, our findings showed that mothers/caregivers who slept under a mosquito bed net would also have their children under five sleep under a mosquito bed net. Thus, mothers/caregivers who slept under ITN were less likely to have no child

PLOS ONE
The use of ITN between children under the age of five and their caregivers  [20]. Malaria knowledge was associated with the use of ITN among mothers of children under the age of five in Ethiopia [40]. Households with at least two children under five years of age were less likely to have no child and all children sleeping under ITN as compared to some children sleeping under ITN. Our study implies that households with at least two children under five would have at least some children sleeping under ITN. That is, at least there are some households with an unequal distribution of ITN with regard to household size, which significantly lowers the use of ITN [41]. This finding is similar to a study conducted in the Gambia and Ghana [31,32].
Furthermore, compared to some children, mothers and caregivers who attended ANC visits 4-7 times during pregnancy were less likely to have had no child sleep under ITN. This implies that mothers or caregivers who attended ANC visits four to seven times would have at least one child under the age of five who used ITN. Similar findings have been reported among Senegalese [42]. ITNs are given to pregnant women at no cost during ANC visits as a vital approach for controlling malaria and increasing coverage and use by both pregnant women and their children under five [9,[43][44][45]. In most areas where malaria is endemic, women sleep with their infants through the first year of life as a protective effect of ITNs delivered to pregnant women during ANC [33,35].
Moreover, socio-economic status is a key variable in assessing the effect of health interventions or programmes in society. It is an indication as to whether the interventions reach the poor or vulnerable groups relative to the well-to-do people in societies. We found that wealthier mothers/caregivers had a higher chance of letting none of their children under five sleep under ITN compared to some children sleeping under ITN. The finding is also consistent with reports from Ghana [32] and Senegal [42]. Also, the Ghana Statistical Service indicated that the percentage of women who sleep under ITN tends to decrease with wealth [31]. However, Asumah et al. found that increasing average monthly income was associated with the utilisation of ITNs in the Kasena-Nankana East Municipality in the Upper East of Ghana [29]. The distinctiveness of each setting and the ITN deployment interventions and strategies may result in a disproportionate order between the well-off and relatively poor categories. As a result, wealthier households are more likely to have access to other malaria prevention strategies and may not use ITN even if they have them [32,46]. Mothers/caregivers who would allow their children to be vaccinated against malaria were 3.22 times more likely to have no child sleeping under an TN as compared to some children using an aITN (RRR = 3.22; 95% CI = 1.117, 9.304). That is mothers/caregivers would feel their children under five would be protected from malaria after the vaccination.

Implications of the current study's findings for malaria control policy and practise in Ghana
The current study's findings have implications for malaria control policy and practise in Ghana. Despite increased household ownership of ITN in Ghana, usage by vulnerable groups such as children under the age of five remains low, as evidenced by the current study and other national reports [10]. The current study, on the other hand, identified some key factors that can be addressed to encourage the use of ITN. The use of ITN by children under the age of five is influenced in part by its use among mothers or caregivers. As a result, increased advocacy for the use of ITN by mothers or caregivers of children under the age of five is required to improve usage among children. ANC provides an avenue for health education and interactions with families to promote positive health behaviours.

Strengths and limitations
We used a nationally representative sample and robust statistical techniques to generate estimates that are generalizable to the entire Ghanaian population of children under five years of age. These findings are important for decision-makers and stakeholders. However, we acknowledge that some limitations also exist. The GMIS is a cross-sectional survey, and the conclusions are limited to statistical associations rather than causal relationships. In addition, the questionnaire relied on self-reported responses, which are prone to recall bias and socially desirable answers. Furthermore, the use of ITN was based on the previous night before the conduct of the study, which might be tentative, as it may not reflect the true nature of the usage of ITN in children under five. That is, respondents might not be using ITN but used it the night before the study was conducted.

Conclusion
The study identified that about three-fifths of both women and children under five slept under ITN. Again, it was found that women who slept under ITN were more likely to have their children under five sleeping under ITN too. ITNs are given to pregnant mothers/caregivers freely during ANC visits as a vital approach for controlling malaria and increasing coverage and use by their children under five. Thus, the target of achieving 85% utilisation of ITN in children under five under the National Malaria Control Programme in Ghana should include usage by their mothers.